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GENDER, SEX and POWER:
Understanding implications of empowering women at
risk of HIV/AIDS
CARE India
1
ACKNOWLEDGEMENTS
Research, Analysis and Writing
• Nabesh Bohidar
• Dr. Jose Sool
• Sandhya Venkateswaran
• B. Srikanthi
Overall Guidance
• Dr. Dora Warren
Field Researchers
• J. Manohar
• Arshita
• Manikyam
• Krishna Kumari
• Baby Sarojini
Technical support
• Anthony Klouda
• Gopal Mukherjee
• George Kurien
• Philip Veigas
Report writing support
• Meenakshie Verma
Overall Support and Facilitation
• Nari Saksham
• CARE staff (SAKSHAM,
Rajahmundry)
2
Contents
Acknowledgements 2
Chapter One: Introduction 4
Chapter Two: context at Rajahmundry 10
Chapter Three: Profile of respondents 13
Chapter Four: What is empowerment for the FSWs? 16
Chapter Five: How does the project contribute to empowerment? 24
Annex 1: 41
Annex 2 45
3
Chapter One: Introduction
1.1 Background:
The HIV epidemic in India continues to affect the country‟s developmental efforts. Current
estimates of HIV infected people are between 2.4 to 2.8 million people. India however, does
not face a generalized HIV epidemic like that seen in Southern Africa. Instead, the epidemic
is focused primarily among particular “high risk groups” or “core groups”. These
populations of primary concern are also some of the most marginalized communities in
India, e.g. female sex workers (FSW), injecting drug users (IDU), and men who have sex
with men (MSM). Preventing HIV transmission with a focus on core groups such as FSW,
MSM, and IDU remains the focus of the HIV prevention program in India.
Female sex workers are particularly vulnerable to HIV infection because of poverty, their
position relative to men in authority, lack of knowledge of their rights, and the stigma
associated with their occupation. Having been identified as one of the primary at-risk
population in India, they have also been further stigmatized as transmitters of the disease.
These structural forces limit the ability of sex workers to protect themselves from HIV.
While technical HIV prevention efforts focus on distributing condoms and raising
awareness, those steps alone are becoming increasingly recognized as insufficient.1
The Indian government‟s policy on HIV/AIDS, managed by and implemented through the
National AIDS Control Organization (NACO) recognizes the complexity of the HIV
problem the country faces and the need for large-scale action that targets structural barriers
as well as individual behavior:
The creation of an enabling environment, which includes policy adjustments,
supportive inputs and empowerment processes of the marginalized groups, is needed
to facilitate behavior change. Public relations efforts and careful program design are
needed to minimize the stigma and marginalization of highly vulnerable groups.
Stigmatizing risk behavior persons leads them further “underground” and is
detrimental to program effectiveness. Targeted interventions to such groups should
be embedded in a broader national program.2
At the same time, Indian law regarding sex work is ambiguous, and therefore problematic.
Sex work itself is legal, but a complicated series of laws and regulations confuse what is and is
not permissible. Sex workers themselves are frequently unaware of the details of the law as it
pertains to their work, and thus are vulnerable to exploitation. Secondly, few interventions
address the structural issues mentioned above.
1
Helweg-Larsen, M. Social psychological perspective on the role of knowledge about AIDS in AIDS
prevention Current Directions in Psychological Science, v.6, n.2, 1997, pp.23-6.
2
From “Lessons Learned of Nat‟l AIDS Control Programme Phase I, (1992-99),”
http://www.nacoonline.org/abt_phase1.htm
4
1.2 Study rationale:
While it is increasingly recognized, that interventions with FSWs need to be broad based and
look at underlying issues relating to structures including power dynamics, there is little
understanding of how projects attempting to address these impact the lives of the FSWs as
well as reduce risk to HIV. There is a need for understanding the character and implications
of empowerment. It is essential to research the agency, structure, and relationships of
women that increase their vulnerability to HIV.
CARE‟s SAKSHAM project in Rajahmundhry, Andhra Pradesh works with FSWs through a
comprehensive approach, which seeks to empower them in order to reduce risk to HIV.
CARE‟s six-country study on Gender, Sex, and Power was an opportunity for carrying out
research to understand the outcomes of such an approach.
1.3 CARE’s six-country study:
As an organization committed to addressing the underlying causes of poverty and social
injustice, CARE has made the advancement of women‟s empowerment a core principle and
a strategic thrust of all its work. CARE values women‟s empowerment both as an expression
of its commitment to equal human rights for all, and as a pathway for enduring impact on
the deep structures that sustain poverty.
Driven by its accountability and learning needs, and by the desire to engage constructively in
policy debates on HIV and AIDS, CARE is committed to establishing a fuller and more
empirically grounded narrative about the impacts of CARE‟s empowerment approaches for
HIV prevention.
The six-country research study examines CARE‟s work with sex workers in Bangladesh,
Cambodia, India, and Peru; garment factory workers in Lesotho; and rural women in post-
conflict Burundi – drawing from the perspectives of over 1800 respondents. Exploring the
lives of women in these diverse contexts offers valuable lessons on the important role
gender norms and power relations play in the global fight against HIV and AIDS. Assessing
how well our approaches support these women in their struggle for a dignified life and
future is an exercise of accountability with profound importance. The women we serve have
a right to describe their own aspirations, to learn how far they have been able to reduce their
vulnerability, and to assess the value of CARE‟s contributions.
For this study, CARE and ICRW collaboratively designed a three-stage Global Research
Framework that incorporates both qualitative and quantitative research methods, and can be
adapted by each of the six countries to suit their specific contexts and projects. Each country
team, along with a local research expert, collected, analyzed, and shared their findings at a
Synthesis Meeting in Cambodia in June 2008.
1.4 The six-country (global) Research Framework: Conceptual design:
The goal of the Global Research Framework is to improve the ways in which CARE‟s
programs understand and respond to the gendered power dynamics that drive women‟s and
5
girl‟s vulnerabilities to HIV within the context of the six country programs. Within the
Global Research Framework, we aim to answer three research questions:
1) What constitutes empowerment as defined by the FSWs who CARE‟s projects
support?
2) How do these projects contribute to empowerment?
3) What linkages do we find between changing levels of their empowerment and their
vulnerabilities to HIV, as described by project participants?
1.4.1 Aims of the Study
At the broadest level, the aims of six-country study are:
1. to generate empirical evidence of the contributions that CARE‟s “empowerment
approaches”3 make towards the empowerment of sex workers and on the prevention
of HIV/AIDS;
2. to better understand the female sex workers‟ experiences, circumstances and
aspirations for empowerment, in order to improve the effectiveness of our current
and future programs;
3. To develop strong evidence-based arguments about “what works” with respect to
HIV prevention with marginalized, high-risk groups.
1.4.2 Specific Research Questions
Three broad research questions were sought to be answered:
(1) What constitutes empowerment for the women these programs support, and are the programs resulting in
such empowerment?
(2) What impact do empowerment approaches and empowerment outcomes have on HIV prevention?
1.4.3 Method of Sample Selection
The active sex workers for the study were selected from the existing project list of 800 sex
workers. For this selection, a stratified random sampling technique was used. Sex workers
were divided into 4 categories based on their association with the CBO. There were a total
no of 475 sex workers who were involved in the Community based organizations (CBOs)
and 325 sex workers who are non-members4. The sex workers were first divided into the
four categories depending upon their length of association with CBOs. Again, they were
further stratified under each category based on the type of sex work as brothel based, home-
based, and street/highway based. A total no 240 sex workers were selected from various
categories, and the sample number was 60 in each category, the detailed sampling
classification is given below.
3
Empowerment approaches explicitly promote the empowerment of sex workers to claim their full human rights as citizens, and not
simply to treat them as disease vectors to be contained.
4
Based on existing project FSW list, November 2007.
6
Types Membership of sex workers in CBOs Non CBO
More than 6 More than 6 Less than Sex Workers
months months –less than 1.5 years
1.5 years
Brothel based 20 20 20 20
Street based/ Highway 20 20 20 20
based
Home based 20 20 20 20
Total 60 60 60 60
Grand Total 240
1.4.4. Rationale for the Sampling Design,
The formation of CBO is the key strategy for empowerment, therefore stratifying the sample
based on CBO membership was considered.
1.4.5 Data Collection:
This study had employed both qualitative and quantitative data collection methods
simultaneously to understand the impact of the empowerment on HIV risk reduction
Structured questionnaire (quantitative)
Interviews with sex workers, using a structured questionnaire, about 240 sex workers aged 18
years and above and belonging to different categories were selected and interviewed. Their
selection will be based on their involvement in the CBO as described in the sampling. 5 The
aim is to identify and understand their vulnerabilities, factors shaping these vulnerabilities,
their impact on HIV, whether programs have been able to address their vulnerabilities, their
level of empowerment, and the impact of empowerment on their HIV risk behavior. The
detailed questionnaire has been provided in the Annexure. A stratified random sampling was
carried out based on their involvement in CBOs
Focus Group Discussions (qualitative)
Focus Group Discussions with sex workers, 10 focus group discussions was held with
different categories of sex workers, depending on their involvement in CBOs. Each group
would consist of 10–15 community members. The groups for FGD were homogeneous and
were based on the typology. The aim has been to understand their perceptions about
empowerment, and how SAKSHAM‟s empowerment framework helped them.
5
Refer to limitations to the study in chapter 5.
7
In depth interviews (qualitative)
In-depth Interviews with empowered sex workers, and 20 sex workers, who have been rated
for their empowerment, were selected and interviewed using qualitative interview guidelines.
The aim of this exercise was to establish case studies on the impact of empowerment on
their lives and reduction in HIV risk behavior.
Key Informant Interviews with Stakeholders (qualitative)
Twelve qualitative interviews were conducted with major stakeholders, like police,
representatives from legal cell, women activists, district health officials etc. The main aim has
been to understand how the attitudes of these stakeholders towards sex workers have
changed over a period and how they have contributed to the structural changes in the lives
of sex workers, to enable them access more social support, and enhance their negotiation
with the general community. It has been thought that, this will strengthen and support the
research data obtained from the sex workers community as to how empowerment has
contributed to their increased quality of life.
1.4.6 Ethical Procedures for the Qualitative Interviews
Project management committee:
Considering the sensitive nature of the profile of FSWs, ethical approval for conducting the
study on sex workers has be sought from the standing ethical committee (Program
Management Committee). 6. The study design and the ethical guidelines, which were
followed during the study, were discussed with the PMC and written consent for conducting
the study was obtained. Following this, an ethical approval was also sought from the
Institutional Review Board of CARE Atlanta.
Informed consent
Written informed consent was obtained from the participants. Interviews were conducted at
a site identified by the respondent as convenient for them which ensured privacy and
confidentiality. The study ensured the privacy and confidentiality of the respondents through
a coding process. The consent forms is provided in the annexure
Risks and Benefits of Participation in the Research
Participants were explained about the risks and benefits of participating in the study. The
risks to participants in this study meant sharing of their identity as sex worker. However, this
information was kept confidential and it has not been shared with anyone outside the
research team. The participants were also explained that while the study may not benefit
them directly, but it may benefit them and others in future.
6
Program management Committee is a standing ethical committee constituted of Sex Workers and the
project staff.
8
1.4.7 Research Investigators
The research team comprised of two social sciences post- graduates. The social scientists
used qualitative method of interviewing the respondents. Apart from them 3 field
researchers from the community were engaged in data collection.
1.4.8 Research Time frame:
The study was completed in 7 months from October 2007 till May 2008.
1.4.9. Data Analysis
Data analysis for the quantitative data was carried out through SPSS. The qualitative data
was analysed manually.
9
Chapter Two: Context at Rajahmundhry
2.1 The Context: FSWs and HIV
Research preceding this study provides valuable insights into the context in which FSWs
operate and vulnerabilities of FSWs towards HIV. The previous studies are (a) an exploratory
study conducted by Population Council in Rajahmundry7; (b) study conducted by Yale
University as part of Project Parivartan, a research effort examining structural interventions
for HIV prevention in India in collaboration with the Gates Foundation8; (c) an internal
assessment conducted by CARE‟s Monitoring Organization Learning Development Unit.9
Many structural forces make female sex workers particularly vulnerable to HIV infection.
Poverty is an undeniable risk factor as desperation to earn meager income forces sex workers
to make unsafe choices. The position of these women relative to men in authority is also
partly responsible for greater vulnerability to disease owing to the complex power
relationships that exist between sex workers and their male clients, partners, brothel
controllers and pimps. Inequitable power relations often render sex workers powerless to
negotiate condom use and other safer sex practices with clients, husbands, or lovers.
Economic necessity and sex workers‟ low social status mean that when a client refuses to use
a condom, or offers more money to not use one, sex workers are typically in no position to
argue. In the Yale study, focusing on sex workers in Rajahmundry, 29.6% reported having
accepted an offer of more money from a client to not use a condom. The same percentage
reported they had never tried convincing a client to use a condom. 10
The Yale study also showed that rates of condom use with husbands are especially low
compared to lovers. Nearly 50% of sex workers participating in their study reported condom
use in their last sexual encounter with a lover, but only 16.9% reported using condoms the
last time they had sex with their husband. In these and all relationships with regular partners,
dynamics of love, attachment, pleasure, and financial dependence further complicate
interactions. There are grave implications for sex workers, their partners, and the wider
spread of HIV. Unfaithful spouses who refuse to use condoms put sex workers at risk, and
many of the women have long-term lovers who are married to other women. In addition,
those women who know they are HIV-positive may not tell their partners for fear of
abandonment, and some husbands still refuse to use condoms even if they know their wife is
HIV-positive. So efforts to combat HIV infection by merely distributing condoms and
7
Mahendra, V.S., S. Mehrotra, B. Srikanthi, S. Panda, A. Sarna, A.K. Jayasree, R. Prasad and N.
Rutenberg. 2007. “Identifying areas for linkages between HIV and SRH for vulnerable populations: An
exploratory study to assess female sex workers‟ sexual and reproductive health needs” Research Update.
Population Council, New Delhi.
8
Project Parivartan, “Results of a Cross-Sectional Study of Female Sex Workers in Rajahmundry, Andhra
Pradesh”, May 2007. http://cira.med.yale.edu/parivartan/resources/reports/surveysummary_0507.pdf
9
Monitoring Organization Learning Development Unit, CARE India, “Community Led Structural
Interventions for Empowerment: An Assessment Report,” 2007.
10 Gender, Rights and HIV: The Effects of Empowerment Strategies on Reducing Risk among Sex Workers (A
Consolidation of Studies of CARE India‟s Saksham Program, Draft, 2007
10
raising awareness are becoming increasingly recognized as insufficient as they fail to address
the underlying social causes.11
Violence is a constant reality for sex workers, and is a consequence of imbalanced
relationships between men and women. The fear of violence also prevents sex workers from
demanding the use of condoms with partners and clients, thus increasing their risk of HIV.
Violent abuse including rape may come from sex workers‟ husbands or partners, clients,
police, or others with whom they may interact, including pimps. Women interviewed for
CARE‟s SII study say they have suffered physical torture at the hands of rowdy clients, been
forced to have sex with police officers, and coerced into sex with multiple men despite
having negotiated with only one client. In these interviews, the women report “risk of
infection” as a risk they associate with police. As a result, they cannot turn to the police for
help and have essentially nowhere to go for even the most basic levels of personal protection,
placing them at ever-higher risk of further abuse and potential infection. Very few women
report the violence they experienced to the police, an NGO, or a sex worker collective. 12
The threat of violence is a powerful disincentive that prevents women from accessing health
services to prevent, diagnose, or treat health problems. Women may be prohibited by their
husband or partner from visiting a doctor. Furthermore, they may also face violence if they
are diagnosed as HIV-positive. This prospect may prevent a woman from seeking out health
care or getting an HIV test, since a positive diagnosis could lead to physical abuse or to being
thrown out of the house by her family or her partner.
Stigma is also a formidable barrier that increases sex workers‟ vulnerability to HIV.
Discrimination causes sex workers to be denied access to health services and safe sex
information. Consequently, many sex workers remain ill informed about HIV and do not
receive treatment for other sexually transmitted infections (STIs). Stigma also has a powerful
and harmful impact on the self-esteem of sex workers. In a profession vilified by society and
characterized by social exclusion, sex workers have low self-esteem. Unable to access quality
healthcare or demand a safe, violence-free work environment, they may also come to believe
that they do not actually deserve such things.
.
Stigma also exists within the sex workers‟ own community. In the Yale study, a startling 74%
of sex workers polled say sex work is immoral. Community based stigma and discrimination
reinforce these attitudes. As a result, there exists a hesitancy to admit to being a sex worker,
which limits the community‟s ability to work collectively to improve their living and working
conditions. Hierarchies amongst sex workers also create an environment for discrimination
against certain groups. Street- and highway-based sex workers, who are typically more
vulnerable to violence, hunger, and mistreatment, are also often looked down upon by the
generally more secure and better off home- and brothel-based sex workers.
11
Helweg-Larsen, M. Social psychological perspective on the role of knowledge about AIDS in AIDS
prevention Current Directions in Psychological Science, v.6, n.2, 1997, pp.23-6.
12
Ibid
11
2.2. The SAKSHAM intervention:
Strengthening Awareness Knowledge and Skills for HIV/AIDS Management (SAKSHAM)
in Rajahmundry, Andhra Pradesh was the focus of our research in India. SAKSHAM‟s goal
is to increase demonstrable leadership and capacity, among India AIDS Initiative partners
and State AIDS Control Societies, for effective HIV/STI prevention in six India AIDS
Initiative states by 2009. Through SAKSHAM, CARE works with sex workers, IDUs and
MSM to reduce their vulnerability to HIV. Using the Community Led Structural
Interventions (CLSI) approach, SAKSHAM creates local processes for problem solving
within these communities. CLSI is an approach in which action is taken in partnership with
the community. CLSI positions the community as the prime actors, not just as passive
“beneficiaries” of interventions.
The activities include:
Select and train peer educators or Social Change Agents to provide information on
risk reduction and increase access to services
Create Drop-in-Centers (DICs) or safe spaces that allow the community to meet,
think, plan, mobilize and act
Develop Community Based Organizations (CBOs) consisting of sex workers
attempting to foster leadership, identify shared problems and solutions, and handle
crises. The federation of CBOs is registered as Nari Saksham
Encourage community led advocacy with the police and media to change attitudes
towards sex work
Establish Crisis Intervention Teams to respond to episodes of violence
Establish Health Committees (comprising of sex workers, doctors and NGO
members) to refer and encourage sex workers to access services, and to monitor the
quality and management of services at the STI clinic
Free provision of condoms distributed by CBOs
12
Chapter Three: Profile of Participants
3.1 Category of respondents:
The frequency of study participants within the four categories is given below. Almost half
were associated with CBOs for more than one and half years.
Category of respondents N %
Sex workers with more than one & Half years of involvement with 111 46
CBOs13
Sex workers with more than 6 months and less than 1& half years 52 22
involvement with CBOs
Sex Workers with less than 6 months of involvement with CBOs 27 11
Sex Workers with no or little involvement with CBOs 50 21
Total 240 100
3.2 Typology:
The respondents were almost equally divided on the typology of sex workers.
Typology N %
Brothel based 76 32
Home based 88 37
Street/Highway based 76 32
Total 240 100
3.3. Age:
The respondents are almost equally divided within the age categories.
101-Age
Frequency Percent Valid Cumulativ
Percent e Percent
Valid 18-25 yrs 42 17.5 17.5 17.5
26-29 yrs 50 20.8 20.8 38.3
30-34 yrs 50 20.8 20.8 59.2
35-39 yrs 47 19.6 19.6 78.8
40-44 yrs 42 17.5 17.5 96.2
over 44 yrs 9 3.8 3.8 100.0
Total 240 100.0 100.0
13
CBO: Community Based Organization
13
3.4: Educational status
Majority of the respondents have never attended school.
102- Educational status
Frequency Percent Valid Cumulativ
Percent e Percent
Valid 1-Never attended 170 70.8 70.8 70.8
school
2- class 1-5 35 14.6 14.6 85.4
3-class 6-10 31 12.9 12.9 98.3
4-class 11-12 2 .8 .8 99.2
5-Graduation & above 2 .8 .8 100.0
Total 240 100.0 100.0
3.5: Caste
The largest proportion among the caste categories was the backward castes, who constitute
around half of the respondents.
103- caste
Frequency Percent Valid Cumulativ
Percent e Percent
Valid 1-SC 67 27.9 27.9 27.9
2-ST 8 3.3 3.3 31.2
3-BC 115 47.9 47.9 79.2
4-General 50 20.8 20.8 100.0
Total 240 100.0 100.0
3.6: Religion
The respondents are equally divided between Hindu and Christians.
104- Religion
Frequency Percent Valid Cumulativ
Percent e Percent
Valid 1-Hindu 110 45.8 45.8 45.8
2-Christian 126 52.5 52.5 98.3
3-Muslim 4 1.7 1.7 100.0
Total 240 100.0 100.0
14
3.7: Marital status
Among the respondents, those who are separated constitute the highest proportion. It is
interesting that an overwhelming 70% of the respondents are separated, widowed, or
divorced.
105- Marital Status
Frequency Percent Valid Cumulativ
Percent e Percent
Valid 1-Currently married 36 15.0 15.0 15.0
2- Separated 106 44.2 44.2 59.2
3-Widowed 50 20.8 20.8 80.0
4-Divorced 13 5.4 5.4 85.4
5-Never married 35 14.6 14.6 100.0
Total 240 100.0 100.0
15
Chapter Four: What is Empowerment for the FSWs?
This chapter seeks to understand the notions of empowerment as mentioned by the
participants themselves. Participants in the qualitative study were asked to talk about what
they meant by empowerment. The responses from the participants were viewed in the light
of CARE‟s Empowerment Framework, which takes into account “agency”, “structure”, and
“relations”.
4.1. Agency
CARE‟s Empowerment Framework defines agency as “the aspirations, resources, actions and
achievements of women themselves. Every woman has agency, and every woman analyzes,
decides, and acts on aspects of her life without CARE being involved. Sometimes she does
so in ways that challenge gendered power inequities and in other times, in ways that
reinforce them. Empowerment involves a journey through which poor women increasingly
use their agency to expand their options and challenge inequities.” 14
CARE‟s SII anchors its exploration of women‟s agency in 10 sub-dimensions (Table 3, 4,
and 5). Women‟s voices, across the six countries, aligned with eight of these sub-divisions
(represented in boldface blue text).
Table 1: Sub-dimension of Agency
Sub-Dimensions Evidence Categories/Indicators
1. Self-image; self-esteem Positive images of self, belief in one‟s abilities, feelings of
self-efficacy
2. Legal / rights awareness Knowledge of laws around issues of women‟s social
positions, status, equality, etc.
3. Information / skills Access to information and skills that a woman deems
helpful or necessary; awareness that such
information/skills even exist
4. Educational attainment Access to and ability to deploy formal and informal
forms of education
5. Employment / control Fair and equitable access to employment opportunities;
of labor fair and equitable working conditions; freedom to chose
forms of labor
6. Mobility in public space Freedom and safety to circulate in public spaces
7. Decision influence in Kinds of decisions that women can make over household
HH finance & child- resources, processes, people, investments, etc.
rearing
14
Martinez E., and K Glenzer, Global Research Framework for CARE‟s Strategic Impact Inquiry on
Women‟s Empowerment
16
8. Group membership / This sub-dimension certainly overlaps with the element
activism below, Relations. Here, at the level of agency, we are
looking at the degree to which women are free to join
groups as a result of their own wishes to do so
9. Material assets owned The kinds of material assets (land, goods, animals, crops,
money) women have the power to control
10. Body health / integrity Access to core health services of acceptable quality;
freedom to make decisions over what happens to a
woman‟s own body; a right to bodily well being and
pleasure
4.1.1 Sub-dimension 1: Self-image, self-esteem
Self-esteem, self-confidence, assertiveness, and self-respect were considered central to
empowerment. Female Sex workers – both associated with CBOs and those who are not --
rated „self-confidence, self-esteem, and self-respect‟ highly among qualities necessary for
empowerment.
One sex worker/CBO member for more than 1.5 years noted:
“I feel that self respect is the first one because we should have faith in ourselves and respect for ourselves.
After that, it (empowerment) would increase. At first we should have faith in ourselves and respect for
ourselves.” (India)
Along with self-esteem, self-confidence, and self-respect, another key aspect, which emerged
from the discussions, was the quality of being comfortable being a sex worker. This was
mentioned as the ability to “tell others that they are sex workers” and “revealing one‟s
identity as a sex worker”. The emphasis on this is due to the stigma associated with sex work
and sex workers in the larger society. Due to this stigmatization, common approaches
towards FSWs has been to view them either as victims (thus requiring measures for
rehabilitation, including coming out of sex work) or as “bad women” (needing corrective
action). One of the key factors that make sex workers hesitate to engage with the general
society and a factor in accepting discrimination towards them is a low self-esteem. One of
the major reasons for a low self-esteem is the general notion that sex workers are immoral
and bad. This is an imbibed value that many sex workers have. Any rising of self-esteem may
involve change in the value that they hold about sex work. The emphasis on being
comfortable as a sex worker is an attempt by the FSWs to instill self-esteem in the very
aspect that stigmatizes them.
4.1.2. Sub-dimensions 2, and 3: Legal/rights awareness
Knowing one‟s rights and possessing correct HIV & AIDS information and knowledge were
seen as empowering.
17
Female Sex workers noted that awareness of various issues relating to themselves and their
health is important for empowerment. They further state that “lack of information and lack
of awareness” are impediments to achieving empowerment (FGD with FSWs associated
with CBOs > 1.5 years).
The FSWs also talk about how an awareness about rights has been instrumental in making
them courageous (daring), where they do not fear the Police as the used to.15
4.1.3 Sub-dimension 6: Mobility in public space
FSWs did not mention mobility in the discussions. This is probably due to existing
opportunities for mobility. FSWs who are in non-home based settings move out of the
home, either for sex work or for the purpose of agricultural labor.
What was strongly mentioned by the FSWs was the importance of “living life without fear”
and reduced violence, especially in relation to the Police.
4.1.4 Sub-dimension 7: Decision influence in household finance & childrearing
FSWs talked about the ability to solve problems as a key aspect of empowerment. Though
they did not specifically mention about household decisions, they said that it is important to
maintain stability and peace in one‟s own house and relatives.
One of the reasons for the low mention of decision making in household finance and child
bearing could be the fact that a large majority of the respondents were either divorced,
separated or widowed and therefore did not stay in a traditional family setting.
4.1.5 Sub-dimension 8: Group membership/activism
Closely tied to CBO work, many FSWs talk about the importance of group membership and
activism as a key to their empowerment. They described one of the key aspects of
empowerment is “chaitanyam” which is to become enlightened to help others.
4.1.6 Sub-dimension 9: Material assets owned
FSWs mentioned being „courageous‟ and “taking decisions” as an aspect of empowerment.
Ownership of material assets did not come up during the discussions with the FSWs.
4.1.7 Sub-dimension 10: Body health/integrity
FSWs addressed body health and integrity in their characterization of empowerment as
access to services, taking care of one‟s own health and the ability to protect oneself from
diseases.
15
Refer to the section on „changes that have taken place‟.
18
Implicit in making decisions to protect one‟s health and physical integrity is the ability to
negotiate with (often) more powerful sexual partners – husbands, lovers, boyfriends, clients
etc. This overlaps with relationship sub-dimension 20: Negotiation/accommodation habits.
Being fearless (daring) is mentioned by all categories of sex workers in the FGDs. Being able
to live almost all groups have mentioned life without fear.
4.1.8 Some additional nuances:
Some additional and nuanced aspects of empowerment emerged from the discussions with
the FSWs. The definitions of empowerment and descriptions of empowered women
extended beyond having the power to help themselves, but to help and support others.
FSWs who were associated with CBOs talked about the importance of „revealing their
identity as sex workers and coming out, living in respect‟ as being central to sex worker
empowerment. They further talked about “Chaitanyam” or being enlightened to serve others
as one of the key aspects of empowerment.
FSWs not associated with CBOs additionally talked about the importance of “meanness” –
perhaps, as a coping or survival mechanism in a “world of cheats” and in light of stigma
against sex workers.
4.2. Structure
CARE‟s Empowerment Framework characterizes structure as “routines, patterns of
relationships and interaction, and conventions that lead to taken-for-granted behavior;
institutions that establish agreed-upon meanings, accepted (“normal”) forms of domination
(who “naturally” has power over what or whom), and agreed criteria for legitimizing the
social order.” Structures include behaviors as well as ideologies and norms that render
behaviors socially acceptable. One of the hallmarks of structure, which makes it quite
difficult to explore in the kind of participatory process that this research followed, is its very
pervasiveness – which naturalizes societal rules and patterns to the point where most people
hardly detect them, and seldom question them.
In our analysis, women‟s voices highlighted three of the eight sub-dimensions (represented
in boldface blue text).
Table 2: Sub-dimensions of Structure
Sub-dimensions Evidence Categories/Indicators
11. Marriage/ kinship rules Degree of freedom and control of marital resources;
& roles equitable inheritance, divorce, and family law more
generally; control of one‟s own body
12. Inclusive & equitable Degree of inclusiveness and equity of laws and practices
notions of citizenship around what it means to be a citizen
19
13. Transparent information Degree to which duty bearers ensure that women have
& access to services the chance to know what they‟re due, how they can
access this, and what to do in the event that they are
denied information or services
14. Enforceability of rights, Enforceability of human rights claims as well as specially
access to justice designed laws and judicial services to promote gender
equity
15. Market accessibility Equitable access to work, credit, inputs, fair prices
(labor/credits/goods)
16. Political representation Extent of women elected and appointed to public office
– in the formal and informal spheres – and their degree
of influence once there
17. Share of state budgets Allocations the state offers for important services,
guarantees, and enforcement mechanisms around issues
central to gender equity
18. Density of civil society The density and quality of civil society organizations that
representation address gender inequity and social exclusion
4.2.1 Sub-dimension 11: Marriage/kinship rules & roles
As most of the FSWs earn for their families, they do “maintain our own authority”. As the
majority of the participants are either divorced or staying away from family, most of the
participants probably did not feel the need for bringing this up during the discussions.
However, While FSWs talked about being courageous and confronting others as aspects of
empowerment, many of the FSWs talked about the need to maintain harmony with relatives.
“I can‟t behave like that (being confrontationists) as they will think that I am like that
always.” “If I behave like that then we will come to blows”. (FGD5-group2)
4.2.2 Sub-dimensions 13 and 14: Transparent information & access to services and
Enforceability of rights, access to justice
FSWs highlighted access to services, such as health services and enforceability of rights as
key to empowerment. Respondents mentioned, „access to services, taking care of one‟s own
health and ability to protect one‟s self from diseases mentioned by the sex workers in the
CBO groups.‟16
16
CARE India preliminary analysis June 2008. Page 2
20
4.3 Relationships
The third component of the A-S-R triumvirate describes relationships as “social relationships
through which women negotiate their needs and rights with other social actors, including
men”. This includes norms and notions of love and marriage, as well as strong social beliefs
about romance.
In our analysis, women‟s notions touched on all five of sub-dimensions that characterize
Relationships (represented in boldface blue text).
Table 3: Sub-dimensions of Relationships
Sub-Dimensions Evidence Categories/Indicators
19. Consciousness of self / Awareness of own power in relation to others, and reliance
others as inter- of others on them. Ability to see leverage and mutual
dependent advantage in joint actions both for self and for others.
20. Negotiation/ Ability and interest in engaging duty bearers, the powerful,
Accommodation habits but also other marginalized social actors in dialogue
21. Alliance/Coalition Extent to which women and women‟s groups form larger
habits alliances and coalitions and seek collective gains
22. Pursuit / acceptance of Skills, confidence, and knowledge to hold duty bearers and
accountability the powerful accountable; recognition that human rights
bring, also, forms of accountability to every individual
23. New social forms Social and structural recognition of non-traditional
household forms. Generation of new kinds of organizing,
new, or altered relationships, new kinds of behaviors.
4.3.1 Sub-dimensions 19 and 21: Consciousness of self/others as interdependent and
Alliance/Coalition habits
An understanding of inter-dependence may have resulted in alliance formation and
unification among the FSWs. Respondents mentioned the importance of „living in unity,
Chaitanyam (enlightenment), working to elevate others suffering, increased networking with
other sex workers, helping and supporting other sex workers‟. They also observed that
“Empowerment is not possible without unity”, and “it is not possible to achieve things as an
individual; one should be united and also think about the plight of others.
4.3.2. Sub-dimensions 20 and 22: Negotiation/Accommodation habits and Pursuit/
acceptance of accountability
We noticed that negotiation with power brokers, such as police, often went hand-in-hand
with the pursuit of accountability or the intention of reducing violence. FSWs talked about
their ability to „cross-question‟ police while „reducing violence‟.
21
4.3.3 Sub-dimension 23: New social forms
The desire for new or altered relationships was discussed by the FSWs. FSWs involved in
CBOs consistently emphasized the importance of “revealing [their] identity as [a] sex worker
… [and] living in respect”. This has come up consistently among those who are in CBOs,
but has not come up at all among those who are not in CBOs. Sex workers who have
mentioned it, have rated it very highly, and say that coming to terms with sex work is an
important factor in being empowered. Sex workers not in CBOs talk about getting respect as
an individual.
4.4 Empowered icons and their qualities
During the FGD discussions, the participants were asked to name the women they think are
empowered and the qualities that make them empowered. These are given according to the
responses from the CBO and non-CBO groups.
CBO groups:
Mother Theresa: She has helped so many people and orphans, people who had
nothing.
Indira Gandhi: Strong leader; has done many good things for the country.
Kiran Bedi: First Indian woman to join the elite Police service
Vijaya shanty, Soundarya, Radha (film actors): Extremely skillful, are able to captivate
the audience, many men are fans.
Vijaya Shanti, Roja Rani (film actors): They are very intelligent, and have supported
many women.
Non-CBO groups:
Vijayshanti: She is good actress and fights the bad people on screen
Shakeela and Silk Smitha (film actors): The have excellent dancing skills and they
“fearlessly expose” themselves on the screen. They “totally captivate the audience”.
Rani Laxmi bai, Rudramma Bai (historical figures): Fought against adversaries, very
brave, fought on horses, and defeated enemies.
Mother Theresa: Has helped many people
4.5. SECTION SUMMARY
The coding and analysis of women‟s notions of empowerment revealed the following things:
Women‟s notions of empowerment captured the agency, and relational aspects more
than they did the structural aspects.
22
New aspects of women‟s empowerment emerged i.e. aspects outside of the A-S-R
framework. The notion of being empowered to help others and the community
illustrates women‟s aspirations that extend beyond that framework. In addition, “living a
life without fear” is closely related to reducing or mitigating violence. Revealing their
identity as sex workers probably addresses overcoming the deeply entrenched stigma and
violence in their lives.
Women‟s notions of empowerment were as much about conforming to gender norms
and functioning within cultural expectations as they were about challenging and
confronting them.
23
Chapter Five: How does the project contribute to empowerment?
This section looks at whether changes have taken place concerning key empowerment
aspects and HIV risk. The responses are a mix of both qualitative and quantitative data. In
reviewing the interventions‟ impact on FSW‟s empowerment and risk to HIV, the report
outlines:
The interventions‟ direct impacts on HIV risk through: knowledge of HIV, access to
services, knowledge and use of testing and health services, and sexual decision-
making and condom use;
The intervention‟s impact on self-efficacy, collective efficacy, and social
consciousness;
Issues of stigma that affect women‟s rights; and
The intervention‟s impact on women‟s awareness of and pursuance of rights.
5.1 Knowledge of HIV
All groups reported changes related to knowledge about HIV and STIs. Sites reported
findings related to knowledge of sexually transmitted infections (STIs) and HIV. In the
qualitative discussions, all the groups who talked about modes of transmission did so
correctly. Many in the groups did talk about coming to know about HIV before the project
started. There were some people in one group of respondents (among those who were not
associated with the CBOs) who said that HIV can spread from “men to women” because
men do not maintain “cleanliness”.
The quantitative study found current knowledge on modes on HIV transmission as high 17.
The differences among the various categories of respondents based on CBO association is
small, e.g. while almost all within CBO groups said that one of the modes of transmission is
though unprotected sex, 82% among the non-CBO respondents said so. Similarly, in terms
of rejecting common myths is concerned, there is not much difference and the awareness
levels are high. However, less than 50% of the respondents correctly identified mother to
child transmission and less than 75% of the respondents correctly identified transmission
through infected blood transfusion. This has implications for programming.
5.2 Access to Services
Project interventions have also brought forth greater access to services in the social
environment. The establishment of clinical services in the project has expanded access to
and quality of services and the development of drop-in health centers. Taking care of one‟s
17
Annex 2
24
health and avoiding diseases, (STI/HIV) was stated by the respondent groups as a current
priority.
Earlier “we had sores on the vagina, rashes, lower abdominal pain earlier too….we used to take
treatment when it became unbearable … and stopped sex work for some time …..” “After CARE
clinic, we know the importance of taking care of our health.” (Case study 3)
Respondents also said “we were treated with respect” and that is why we encouraged
others to access the clinical services. (Case study 6)
In the quantitative study, it is found that almost all who had symptoms in the last six months
have sought treatment.
Table 4
Frequency Percent
Sought treatment Yes 180 93.75
No 12 6.25
Total 192 100.0
Further, all those associated with CBOs have sought treatment while 40% among those not
in CBOs have not sought treatment, in spite of having symptoms.
Table 5
Sought treatment for the problems * Category of CBO Cross tabulation
Category of CBO
In In CBO
In CBO CBO<1.5yrs <6mont Not in
>1.5yr >6month hs CBO Total
Sought yes Count 92 45 25 18 180
treatment for % within
the problems Category of 100.0% 100.0% 100.0% 60.0% 93.75%
CBO
No Count 0 0 0 12 12
% within
Category of .0% .0% .0% 40.0% 6.25%
CBO
Total Count 92 45 25 30 192
% within
Category of 100.0% 100.0% 100.0% 100.0% 100.0%
CBO
25
5.3. Knowledge and Use of HIV Testing and Health Services
Knowledge and use of HIV testing and health services emerged as a finding. The data
showed that a high percentage of sex workers had tested for HIV (70%) and all were aware
of their HIV status. The research suggests that this is due to the high importance given to
voluntary testing along with HIV prevention activities. This could also be because of the
high level of awareness about the condition of HIV positive sex workers and the resultant
efforts of the CBOs to set up special solidarity groups of HIV positive sex workers. The data
shows that sex workers who participated in the CBO were more than twice likely to test for
HIV than non-participants (Graph A).
Graph A
HIV testing and Aware about status
100
90
80
70
Percentage
60
Tested for HIV
50
Aware about status
40
30
20
10
0
CBO member >1.5years CBO member >6m CBO member < 6 months Not member of CBO Total
<1.5years
5.4 Sexual Decision-making and Condom Use
For this domain, we included data on sexual decision-making and use of condoms including
who decides whether to use a condom and respondents‟ confidence in suggesting or
negotiating condom use with partners.
From the quantitative study, it is clear that almost all can refuse to have sex if they do not
want to.
26
Table 6
214 Can you refuse to have sex if you do not want to have sex?
Cumulative
Frequency Percent Valid Percent Percent
Valid 1 236 98.3 98.3 98.3
2 4 1.7 1.7 100.0
Total 240 100.0 100.0
Similarly, as far as taking the decision about the number of clients that they would have each
day is concerned, an overwhelming majority said that they take that decision.
Table 7
417 Can you decide on the number of clients each day?
Cumulative
Frequency Percent Valid Percent Percent
Valid 1-yes 208 86.7 86.7 86.7
2 31 12.9 12.9 99.6
98 1 .4 .4 100.0
Total 240 100.0 100.0
The use of condoms with various partners was explored. Condom use with clients overall
was high with 88% of respondents reporting they always use a condom with clients. The
data also reveals that the likelihood of sex workers using condoms with clients increases with
the duration of association with the CBO. It may be noted that 72% of the sex workers who
are not in CBOs also always use condoms with clients. This may be due to other HIV-
related efforts in the community, or informal networking among the FSWs, which
emphasize the necessity of always using condoms. Furthermore, increased understanding by
clients around the risks of HIV could also help explain the high percentage of condom use
with clients. Despite the high use of condoms with clients, condom use with temporary
husbands and husbands are lower for all women. Here also, the use of condoms is higher
among those who are in CBOs for at least 6 months than those who are not in CBOs. The
reasons given for this vary, but suggest that love and trust play an important role concerning
condom use with temporary husbands. Some respondents also spoke about the fear that
temporary husbands might leave them. Other respondents reported that because they
operate as secret sex workers (without the knowledge of husbands); they have not been able
to use condoms with husbands. However, overall the number of women who currently have
husbands is small.
27
Graph B
Condom use with Partners (always)
120
CBO member
97 >1.5years
100 88 88
78 CBO member >6m
80 72 <1.5years
60 54 CBO member < 6
43 40 months
40 29 33
Not member of CBO
20 13 11 16 16
0 Total
0
Client "Temp Husband" Husband
Some of the qualitative data strongly describe the ways in which the project has been
instrumental in supporting FSWs to use condoms always with clients. The excerpt below
is from a case study.
Earlier some clients used to force us (“Rhubab chese vallu”) not to use condoms, and also demand free sex,
while some would pay as less as Rs 30. I only heard about HIV but did not know much. I did not even
know about condoms at that time. Even though, I was using them, I was not able to insist that they use
condoms. I used to tell them to use condoms but one out of 10 would not use condom. However, I was not
able to say anything to them, as I was scared to speak and due to fear of violence. Clients used to pay very less
and sometimes used to demand free sex as I was doing sex in their area. I could not say a single word. I was
in such a vulnerable condition and could not fight with them, as I needed to go there everyday.
Initially when one sex worker introduced me to CARE, the staff recognized that I have all the skills needed
to talk, train people. …For me the real change took place because of the trainings and the materials given.
After the trainings, I used to share my learning with the sex workers and the truckers who come and stop
near the highway teashops. I started to insist on condom use. One day ….a trucker wanted to have sex have
sex without condom. He insisted and then I went to him, slapped him with my slipper. When the others saw
reacting this way, they also scolded the trucker saying, “She is teaching us good things about health, why are
you challenging such a woman?” Then he (trucker) felt ashamed and left. Later, after a month, he came with
28
a packet of tea powder from Calcutta ( as he is from Calcutta) and handed over to the tea shop owner to give
it to me as his gift” Case study 1
5.5 Self Efficacy
5.5.1 General self-efficacy:
The participants in the FGDs overwhelmingly state that there have been major changes that
have taken place in relation to their self-esteem. In the quantitative study, a number of self-
efficacy questions were asked and the participant‟s responses were captured in terms of the
degree of agreement or disagreement.
Self-Efficacy 1 (I can always solve problems if I try hard enough):
In the quantitative survey, a majority of the respondents strongly agreed (73%) to the above
statement.
Table 8
6201 (Self Efficacy 1
Valid Cumulative
Frequency Percent Percent Percent
“I can always disagree 4 1.7 1.7 1.7
solve neither agree nor
56 23.3 23.3 25.0
problems if I disagree
try hard agree 6 2.5 2.5 27.5
enough : Strongly agree 174 72.5 72.5 100.0
Total 240 100.0 100.0
Self-Efficacy and Relationship with other indicators:
Self-Efficacy1 and association with CBO
There is a strong association. An overwhelming majority (84%) of sex workers (more than
one and half years) strongly agree whereas less than half of the sex workers (no CBO
association) reported so.
29
Table 9
“I can always solve problems if I try hard enough : * Category of CBO Cross tabulation
Category of CBO
In
CBO<1.5 In
In CBO yrs>6mon CBO<6mo Not in
>1.5yr th nths CBO Total
“I can always disagree Count 1 1 0 2 4
solve % within
problems if I Category of .9% 1.9% .0% 4.0% 1.7%
try hard CBO
enough :
neither agree Count 16 12 5 23 56
nor disagree % within
Category of 14.4% 23.1% 18.5% 46.0% 23.3%
CBO
agree Count 1 0 2 3 6
% within
Category of .9% .0% 7.4% 6.0% 2.5%
CBO
strongly agree Count 93 39 20 22 174
% within
Category of 83.8% 75.0% 74.1% 44.0% 72.5%
CBO
Total Count 111 52 27 50 240
% within
Category of 100.0% 100.0% 100.0% 100.0% 100.0%
CBO
30
Self-efficacy 1 and typology:
Street based sex workers report a lesser proportion (55%) of those who strongly agree to the
above statement than proportions among the other categories.
Table 10
6201 * 003 Cross tabulation
003 (typology)
1-brothel 2-home 3-street Total
6201 disagree Count 1 2 1 4
% within
1.3% 2.3% 1.3% 1.7%
003
neither Count 16 10 30 56
agree % within
nor 003 21.1% 11.4% 39.5% 23.3%
disagree
agree Count 0 3 3 6
% within
.0% 3.4% 3.9% 2.5%
003
strongly Count 59 73 42 174
agree % within
77.6% 83.0% 55.3% 72.5%
003
Total Count 76 88 76 240
% within
100.0% 100.0% 100.0% 100.0%
003
Self-efficacy 1 and income earned from sex work:
Those in the higher income group, report a higher proportion (77%) of those who strongly
agree to the above statement than proportions (57%) among the lower income category.
31
Table 11
6201 * 112re Cross tabulation
Income earned from sex work
(re)
Lower Higher
income income Total
6201 disagre Count 3 1 4
e % within 112re 5.9% .5% 1.7%
neither Count 18 38 56
agree % within 112re
nor
35.3% 20.1% 23.3%
disagre
e
agree Count 1 5 6
% within 112re 2.0% 2.6% 2.5%
strongl Count 29 145 174
y agree % within 112re 56.9% 76.7% 72.5%
Total Count 51 189 240
% within 112re 100.0% 100.0% 100.0%
The findings also suggest that street workers are less likely to strongly agree to SE1 than
home and brothel based sex workers, though the difference is not as stark as in the case of
CBO membership. Further, Age is not a major indicator among those who strongly agreed
with SE1. This is similar among the various education groups. There are no major
differences within the categories for either educational status, or religion or marital status.
5.5.2 Self efficacy concerning sex work
One of the key factors that make sex workers hesitate to engage with the general society and
a factor in accepting discrimination towards them is a low self-esteem. The sex workers
themselves have ranked having a positive self-esteem as one of the most important
indicators for empowerment.
For the sex workers, self-esteem is intrinsically connected with the value that they
themselves attach to sex work. One of the major reasons for a low self-esteem is the general
32
notion that sex workers are immoral and bad. This is an imbibed value that sex workers
have. Rising of self-esteem may involve change in the value that they hold about sex work.
From bad women to proud sex workers
In the quantitative study one indicator regarding degrees of agreement (& disagreement)
with the statement “I and proud of being a sex worker” was looked into. The study finds
that a majority of the respondents (55%) agree to the statement, “I am proud of being a sex
worker” and 60% either agree or partially agree to the above.
Table 12
201A (I am proud of being a sex worker)
Valid Cumulative
Frequency Percent Percent Percent
Valid 1 agree 131 54.6 54.6 54.6
2 partially
16 6.7 6.7 61.2
agree
3 disagree 93 38.8 38.8 100.0
Total 240 100.0 100.0
Profiling:
The profiling of those who agreed to the statement “I am proud of being a sex worker”
reveals that as far as relationships with age is concerned, there is not much difference, except
that a larger proportion (71%) among those who are the youngest (18 to 25 years), agree
with the above statement than the other groups.
Further, there is no skew towards any particular category under the variables of educational
status, religion, and typology of sex work, though within the latter, a marginally lesser
proportion of street workers agree to this in comparison to brothel and home based sex
workers. .As far as the caste composition is concerned, a higher proportion among the
backward castes (62%) agree to the above statement compared to 46% among the Scheduled
tribes and general castes.18 The study also reveals that those who are never married (71%)
and currently married (61%) have a higher proportion saying that they agree with the above
statement in comparison to those who are separated (51%), widowed (46%), and divorced
(54%).
Association with CBO
There is strong association, as an overwhelming majority (80%) of those who agree to the
statement, are sex workers who have either been associated with CBOs for more than six
months. Further, among the sex workers who have been associated with CBOs for more
18
The traditional Kalavantalu castes belong to the Backward castes and the Dommeru castes belong to the
Scheduled castes.
33
that one and half years, 64% agree with the above statement compared to only 26% of Sex
workers without any CBO association. In fact, any association with CBOs seems to double
the chance of FSWs agreeing with the statement.
Table 13
201A * 001 Cross tabulation
001 (duration of association with CBOs)
2(6m- 4 (no
1(1.5yrs+) 1.5yr) 3(<6mon) association) Total
201A 1 agree Count 71 34 13 13 131
I am % within 001 64.0% 65.4% 48.1% 26.0% 54.6%
proud
% of Total 29.6% 14.2% 5.4% 5.4% 54.6%
of
being a 2 Count 0 1 3 12 16
sex partiall % within 001 .0% 1.9% 11.1% 24.0% 6.7%
worker y agree
% of Total .0% .4% 1.2% 5.0% 6.7%
3 Count 40 17 11 25 93
disagre % within 001 36.0% 32.7% 40.7% 50.0% 38.8%
e
% of Total 16.7% 7.1% 4.6% 10.4% 38.8%
Total Count 111 52 27 50 240
% within 001 100.0% 100.0% 100.0% 100.0% 100.0%
% of Total 46.2% 21.7% 11.2% 20.8% 100.0%
5.6 Collective Efficacy (including collective action/external influence and
networking with other groups)
FSWs discussed the benefits of group action – solving each others‟ problems, change in the
way they dress and how they spend their money, a reduction in police violence (possibly
through advocating and negotiating for their rights), and a general sense of unity.
“It is not possible to achieve things as an individual; one should be united and think about the plight of
others”
“We realized that even if she is a sex worker in the same locality, what is the harm? We can live like
sisters. First, they started believing it and then made other sex workers in the area believe in that. They
also said that a stage has come now, where we support a girl to find a client when we know that she
34
really is in need of money. We are able to see the benefit of coming together.” (Group 1, > 1.5 years in
CBO-India).
“Earlier we used to drink with all the money we had earned and never used to wear proper clothes. We
used to invest money in our partners. Now we are buying TV, clothes and cupboards and are saving our
money for our future. We have become smart this way now. My own son ill treated me and threatened to
send me to jail if I do not give him all the money that I earned from sex work. My two sisters abandoned
me as I am doing sex work. So even if I lost two sisters, I gained 1000 sisters through the society
(CBOs), and they give me courage”. – (Sex worker strongly associated with CBO for more than 1.5 yrs,
Case study #6 India)
“Once upon a time if police people come to us we used to run away from there, or we used to hide like
that we used to do, they used to beat us when ever they saw us. Now that beating has stopped. This has
happened as we came together. We have managed to do that. We have solved it ourselves.” (India)
A key informant from the police corroborated the result of sex workers coming together:
“We used to think it was really silly that CARE was working on such a theme as sex workers. Later
on, after learning about their activities, we started feeling that they were doing the right thing. We used to
treat sex workers with contempt, thinking what they were doing was wrong. We never gave them
importance. There is increased awareness of their rights and they have become strong by forming a society.
One sub inspector of police who came from Cuddapah was accused of man handling sex workers as per
human rights violation act. I think it was because of the awareness that CARE had brought that this
case was revealed. The SI was warned and the SI also apologized, after which the cases were
withdrawn.” (Key informant interview, Police, India)
A revealing difference emerged between the manners in which sex workers highly involved
in a CBO viewed the benefits of being in a group versus sex workers not associated with a
CBO. While the former group had confidence in their ability to “handle” or manage
customers and police, the latter group‟s responses reflected a sense of helplessness and an
inability to change the environment in which they work.
Sex workers also talked of empathy, sharing, compassion, a realization of sisterhood, and a
sense of giving so other women are not victimized. Most of these „outcomes‟ resulted from
women coming together in groups. “Social consciousness” is perhaps closest to
“consciousness of self/others as inter-dependent” – sub-dimension 19 for the relationship
aspect for women‟s empowerment, as defined by CARE‟s SII.
“It is not possible to achieve things as an individual; one should be united and think about the plight of
others” (CBO member, India)
This was corroborated through the quantitative findings.
One of the indicators that the sex workers them selves have attributed, as empowerment is a
sense of solidarity with other sex workers. In the quantitative study one of the questions
asked was about the degrees of agreement (and disagreement) with the statement “I feel and
strong sense of unity with other sex workers”. In the study, about three fourth (74%) of the
respondents agreed with the statement.
35
Table 14
201D- I feel and strong sense of unity with other sex workers”
Cumulative
Frequency Percent Valid Percent Percent
Valid 1 agree 178 74.2 74.2 74.2
2
partiall 45 18.8 18.8 92.9
y agree
3
disagre 17 7.1 7.1 100.0
e
Total 240 100.0 100.0
Helping others and trying to support others has been stated as a characteristic of
empowerment. When asked if they have tried to bring other sex workers to a Drop in
Centre, 45% said that they did so in the last 6 months.
Table 15
304 - tried to bring other sex workers to a Drop In Centre
Cumulative
Frequency Percent Valid Percent Percent
Valid 1-yes 107 44.6 44.6 44.6
2-no 82 34.2 34.2 78.8
98 51 21.2 21.2 100.0
Total 240 100.0 100.0
Another aspect of self-efficacy related to taking decisions within the household was also
mentioned. The quantitative study also reveals that almost all the FSWs scored high on being
able to take household decisions including decisions regarding their children. However, the
participants did not attribute this to the project. It is possibly due the fact that most of the
FSWs do not stay in traditional settings with their husbands. Further, the respondents said
that “because it is they who earn for the family, they are able to take decisions”.
36
5.7 Stigma, Self-Esteem and Self-Confidence
The study found reports of learned or deliberate behaviors that provided sex workers with a
sense of integration into mainstream society. Sex workers talked about “people listening” to
them. There were examples of women dressing better after being involved in the project and
gaining greater respect within the community. This „socially acceptable‟ behavior, it seems,
goes hand in hand with reduction of stigma, especially in self-directed stigma of sex work.
There is a close link between reduced self-stigma and how the sex workers are received and
perceived by people around them.
FSWs credited solidarity groups for their pride and conviction to express their views in
addition to greater self-esteem, confidence, solidarity, shared responsibilities, and mutual
respect.
“Today we are able to achieve many things. There is a change in our lives also. We can go and talk to
ten people and speak on a stage with hundreds of people listening.” (Sex worker, India)
Further, researchers asked sex workers whether they have observed any change in the
behavior of the general community towards sex workers. The researchers reported that sex
workers associated with CBOs for more than six months were two times more likely to have
observed positive changes among the general community than the respondents who were
not associated with CBOs.
5.8 Awareness and Pursuance of Rights
Researchers reported that sex workers associated with CBOs for any length of time were two
to three times more likely than those not associated with CBOs to have observed positive
changes in the behavior of the police towards sex workers. In addition, a higher percentage
of sex workers in home-based settings reported this change compared to street-based sex
workers.19 It is possible that the “observed change among police” has been the cumulative
result of constant negotiation between sex workers and the police, as well as the ability of
sex workers to address police violence by coming together and demanding their rights.
A respondent from the police corroborated this trend when he remarked:
“We used to think it was really silly that CARE was working on such a theme as sex workers. Later
on, after learning about their activities, we started feeling that they were doing the right thing. We used to
treat sex workers with contempt, thinking what they were doing was wrong. We never gave them
importance. There is increased awareness of their rights and they have become strong by forming a society.
One sub inspector of police who came from Cuddapah was accused of man handling sex workers as per
human rights violation act. I think it was because of the awareness that CARE had brought that this
case was revealed. The SI was warned and the SI also apologized, after which the cases were
withdrawn.” – (Key informant interview, Police, India)
19
Appendix F Cross tab table B
37
The quantitative study also reveals that almost all agree to the statement “sex workers deserve rights like
any other worker”
Table 16
Self Efficacy about sex work (Sex workers deserve rights like any
other worker’ )
Cumulative
Frequency Percent Valid Percent Percent
Valid Agree 231 96.2 96.2 96.2
Partially Agree 5 2.1 2.1 98.3
Disagree 4 1.7 1.7 100.0
Total 240 100.0 100.0
SUMMARY
In this section, we looked at empowerment and HIV-related domains. The following
domains revealed changes, attributed to the project, except those related to HIV knowledge
and self-efficacy regarding household decision-making.
HIV knowledge: The study finds that there has been an increase in the HIV knowledge,
though respondents said that they have had access to HIV knowledge prior to the
intervention as well. The study found that there are gaps in complete and correct knowledge,
especially related to whether mother to child transmission and blood transfusion are modes
through which HIV can be transmitted. These have programmatic implications and
implementers need to take note of this.
Access to health services: The study found that there has been increased access to the health
services, especially due to the opening of the clinical services, and the respectful behavior of
the clinic staff. Secondly, a majority of the respondents have tested for HIV and are aware
about their HIV status. The study finds that there is a difference between those who are in
the CBOs and those who are not associated with the CBOs. Those associated with CBOs
Self-efficacy regarding sexual decision-making: FSWs have indicated that they are better able
to assert themselves. Almost all FSWs reported high self-efficacy with regards to „being able
to refuse sex if they did not want to‟ and „being able to decide on the number of clients each
day‟.
38
General self-efficacy: General self-efficacy is also high among the participants. If we consider
association with CBOs and Self Efficacy 1 (SE120), we find that those with nore than 1.5
years of association with the CBOs are twice likely to strongly agree with SE1, than those
with no association. Similarly, even those who have a lesser duration of association with
CBOs are likely to strongly agree more than 1.5 times with SE1 than those who are not in
CBOs. This suggests that there is a high co-relation between CBO membership with SE1.
Collective efficacy: Collective efficacy was strongly reported from the participants as a direct
result of the intervention. This has further led to changes in the Police and the general
community.
Stigma related to sex work: The respondents, especially in the CBO groups were able to deal
with stigma related to sex work at an individual level. Instead of being ashamed of their
work, they felt that they were not doing any thing wrong and were proud of it.
Knowledge and exercise of rights: The study finds that there is increase in the knowledge of
rights and the ability to fight back.
However, there were also mixed outcomes reported:
Among sex workers, condom use was high among clients, but not among husbands
or lovers
Project impacts more robustly impacted certain groups (such as those in CBOs
versus those not in CBOs)
20
“I can always solve problems if I try hard enough”
39
5.9 Limitations of the research/design
The research/design had a number of limitations. These are given below.
Major limitations in the conduct of the research include:
The SAKSHAM project did not have a baseline to compare data. Therefore, changes
attributable to the project are based on the discussions with the respondents.
During the design of the study, the project list of FSWs was employed for random
sampling. However, the information on the project list about the FSWs association
with CBOs and the FSW‟s own categorization of themselves was at variance. Thus
while the FSWs were randomly selected, the researchers did not get equal
participants from all the four (CBO duration) categories.
Some of the questions related to certain domains in the global study were missed in
the study.
40
Annex 1
Project Approach and Activities in brief:
SAKSHAM Project:
SAKSHAM, which in Hindi means able, self-reliant or empowered, is part of Avahan, the
India HIV/AIDS Initiative of the Bill & Melinda Gates Foundation. CARE‟s mission in
India is to facilitate lasting change among vulnerable groups. Through SAKSHAM, CARE
works with sex workers, Intravenous Drug Users (IDUs) and Men having Sex with Men
(MSM) to reduce their vulnerability to HIV. Community Based Structural Intervention
(CLSI) is the approach that SAKSHAM fosters to create local processes for problem solving
within these communities. SAKSHAM operates out of Rajahmundry in the East Godavari
district of Andhra Pradesh, assisting Avahan State Lead Partners (SLPs) in the six high
prevalence states of India - Andhra Pradesh, Tamil Nadu, Karnataka, Maharashtra, Manipur,
and Nagaland.
Previous interventions for combating HIV have targeted key populations (e.g. sex workers,
intravenous drug users, migrant workers, men who have sex with men, and truck drivers),
perceiving them to be vectors of the HIV epidemic. They are often faced with stigma, which
compounds their economic and social vulnerability to HIV/AIDS
The SAKSHAM program moves beyond traditional public health and behavioral issues and
supports the key populations to address the structures, which increase their vulnerability.
SAKSHAM attempts to reduce these structural gaps through the Community Led Structural
Interventions (CLSI) approach, in which action is taken in partnership with the community.
CLSI positions the community as the prime actors, not just as passive “beneficiaries” of
interventions. This empowerment strategy gives program participants, most of whom have
been marginalized, ownership over the process and the outcomes.
CLSI rests on three pillars:
1. Mobilizing community by initiating a process of active participation to establish their
rights and privileges
2. control over access to and utilization of
services by the sub-population
3. Building an enabling environment to sustain
and keep control on practices
CLSI recognizes the inherent rights of the individual
and community to plan implement and monitor
programs. It is a process, which facilitates the
empowerment of community, unambiguously reflected
in ownership of program and services. As an
41
important strategy, it promotes self-organization as a means to empowerment.
Strategies:
Influencing socio-political context that shapes behavior and practices
Addressing factors that make individuals and community vulnerable to HIV.
Helping remove the barriers that impede access to relevant information and services
Enable individual/community to act based on their decisions and skills
Create an environment to sustain changed behavior and safer practices.
Leading by Example (Social Change Agents)
In SAKSHAM, Peer Educators, or Social Change Agents (SCAs) play the role of being the
trusted providers of information on risk reduction and help people access related services in
a productive way. It is through the Social Change Agents that SAKSHAM focuses on
individual, cognitive and group empowerment and action.
The Social Change Agent is a peer from the community, someone who belongs to the same
societal group, staying in the same geographical area, and is usually of a similar economic
background. This is in keeping with long standing theories of behavior change, which
suggest that communities are more receptive to changing behavior if the motivator or
educator is a person from the same community. However, in CLSI, the peer educator‟s role
is broadened.
Drop–in–Centre
Creating space for communities that have so far remained on the fringes is a cornerstone of
the SAKSHAM strategy. The Drop–in–Centers (DICs) are multipurpose safe spaces that
allow the community to think, act, and lead processes. These spaces, in their enabling, non-
judgmental environment encourage communities to collectivize, mobilize, and advocate
from the front. They allow women to take a breather when the going gets tough, to learn
skills that make their lives comfortable, and to discover that their individual silences now
have a collective voice. It is the private space where trauma and crises issues are handled – a
space where plurality lends itself to unity.
As women come together, over a period the DIC transcends from being a safe resting-place
to a place where they share their experiences, successes, and woes. Of course, for the DICs
to facilitate aggregation, it is important that its location is community friendly, and that it has
elements that attract, comfort, and engage community members. This includes the creation
of a comfortable environ, and simple facilities such as a space to rest, mattresses and pillows,
clean bathrooms, some basic indoor games, etc. These over a period have evolved in
SAKSHAM, and begun to include competitions, information on health issues, classes on
literacy, legal literacy, skill development sessions, etc.
Community Based Organizations
Within the AVAHAN framework, every Community Based Organization (CBO) is an
organic entity with identified aims and objectives, and locally determined priorities of life and
livelihood. The mobilization and coming together of sex workers as organized groups is
crucial in the attempt to change power structures. This eventually reduces a community‟s
42
vulnerability to HIV infection. Currently 12 cluster-level CBOs are federated at the project
level. The project level CBO is registered as Nari Saksham.
The overarching vision of each CBO is to foster community leadership, to help identify
shared concerns and their corresponding answers. The formal registration of these CBOs
leverages their efforts in advocacy, crisis handling, and trauma management, apart from the
routine outreach related activities that they undertake.
Enabling the Environment
In SAKSHAM, sex workers advocate for their own cause (Self Advocacy). This is done
through their capacity building and facilitation towards enhanced communication skills,
raised self-esteem, exhibiting leadership qualities, and better knowledge on the rights of sex
workers. CBOs, especially Nari Saksham and GMS, have undertaken a range of advocacy
related activities.
Community led advocacy, along with positive police intervention, media coverage, as well as
incentives for entrepreneurship from District Administrative machinery has kept spirits high
within SAKSHAM. All these signal towards an enduring process of empowerment and
sustainability
Crisis Intervention. Sex workers live and work invisible lives. The ambiguous legal
framework around sex work in our country, as also the stigma and shame bound nuances
around sex work, a lot of times forces them to work in secret, or in confinement. They take
enormous risks. The work environment is fraught with risks of harm and violence. Violence
within the sex work environment is prevalent at all levels. For many, the violence can be
directly physical, and for others, it takes other, more insidious forms.
While on the highways and streets the issue of harm and violence is more pronounced, even
those who work in the relatively secure environs of a home or a brothel house are not
insured from violence. They have to deal with abusive and uncooperative clients. The police
routinely harass them. In addition, very often, they are swindled financially. As a norm, sex
workers have neither social nor legal protection. They are often at the mercy of other people
in the power structure.
Increasing Control over Access to Services
SAKSHAM recognizes the intrinsic linkages between sex work, STIs and HIV. It bases its
strategy on the premise that STI management is central to HIV prevention. It also
recognizes that stigma and social exclusion restrict sex workers from accessing health
services. In line with its mission to facilitate healthy and safe choices for marginalized
groups, SAKSHAM STI clinics not only cater to the community, but are also community
driven and managed. This results in proactive accessing of health information and services.
Not only do community members avail these facilities, they also motivate others to do so.
STI check ups, surveillance, and follow-ups are all being routinised. The community plays a
pivotal role in monitoring and evaluation of services on a systematic basis. The STI
Management Committee or “Arogya Brundham”, [a Telugu word literally translating into
Health (Arogya) Committee (Brundham)], supervises and monitors the clinic activities; it
also decides the location and timing of the mobile clinics, depending on where the outreach
43
is to be intensive. The STI Management Committee has about twenty five members, and
constitutes of community members, doctors, and others.
Condoms: Condoms are given by the project and the distribution is managed by the CBOs.
Condoms are provided free.
Context at Rajahmundry:
East Godavari has a complicated mosaic of sex work patterns and accounts for a high
prevalence of HIV. Very high levels of mobility, contractual sex work, housewives operating
in secret, women soliciting on streets and highways, dancing troops and brothels create a
scenario of highly vulnerable yet an extremely difficult canvas to reach out to.
44
Percentage
0
20
40
60
80
100
120
Table 1
Unprotected sex without
100100
96
condom-yes
82
88
Sharing
81
injections/needles/syringes
52
-yes
64
53
Mother-to-child
40
33
transmission-yes
30
75
Transfusion of infected
67
41
blood-yes
52
96
Kissing-no
45
84 85 84
Annex 2
95
88
Mosquito bite-no
96
84
95
98
Sharing food/drink/utensils
93
of infected person-no
86
Correct Knowledge of HIV transmission
Sharing clothes of infected
99 98
person-no
96
86
Sharing toilet-no
97 98 96
84
CBO
6 months
>1.5years
CBO member
CBO member
Not member of
>6m <1.5years
CBO member <
Condom use with Partners (always)
120
CBO member
97 >1.5years
100 88 88
78 CBO member >6m
80 72 <1.5years
60 54 CBO member < 6
43 40 months
40 29 33
Not member of CBO
20 13 11 16 16
0 Total
0
Client "Temp Husband" Husband
46
201A * 101 Cross tabulation
101 age
1(18- 2(26- 3(30- 4 (35-
25) 29) 34) 39) 5 (40-44) 6(>44) Total
I am Agre Count 30 26 28 20 23 4 131
proud e % within 52.0 56.0
of 71.4% 42.6% 54.8% 44.4% 54.6%
101 % %
being
% of Total 10.8 11.7
a sex 12.5% 8.3% 9.6% 1.7% 54.6%
% %
worker
Parti Count 2 4 3 5 1 1 16
ally % within
agre 4.8% 8.0% 6.0% 10.6% 2.4% 11.1% 6.7%
101
e
% of Total .8% 1.7% 1.2% 2.1% .4% .4% 6.7%
Disa Count 10 20 19 22 18 4 93
gree % within 40.0 38.0
23.8% 46.8% 42.9% 44.4% 38.8%
101 % %
% of Total 4.2% 8.3% 7.9% 9.2% 7.5% 1.7% 38.8%
Tota Count 42 50 50 47 42 9 240
l % within 100.0 100.0
100.0% 100.0% 100.0% 100.0% 100.0%
101 % %
% of Total 20.8 20.8
17.5% 19.6% 17.5% 3.8% 100.0%
% %
47
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